bartee paper on ridge preservation

7/31/2019 Bartee Paper on Ridge Preservation

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CLINICAL

Journal of Oral Implantology 187

EXTRACTION SITE RECONSTRUCTION FORALVEOLAR RIDGE PRESERVATION. PART 1:RATIONALE AND MATERIALS SELECTION

Barry K. Bartee, DDS, MD

KEY WORDS

Alveolar ridge resorptionGuided tissue and bone regenerationBone graftingBone augmentationHydroxylapatiteXenograftAllograftAlloplastBioglassPTFE

Barry K. Bartee, DDS, MD, is a diplomate,American Board of Oral Implantology/ImplantDentistry; a fellow, American College ofDentists; and is in private practice limited toimplant dentistry in Lubbock, Tex. He is alsoclinical assistant professor, Department of

Surgery, Texas Tech University HealthSciences Center, School of Medicine, Lubbock,Tex, and adjunct clinical professor, Texas A&MBaylor College of Dentistry, Dallas, Texas.Please address correspondence to Dr Bartee at3234 64th Street, Lubbock, TX 79413.

Disclosure of commercial affiliation: clinicalconsultant, Oral Tissue Regeneration,Osteogenics Biomedical, Inc, Lubbock, Tex.

Alveolar ridge resorption has long been considered an unavoidable consequence

of tooth extraction. While the extent and pattern of resorption is variable among

individuals, there is a progressive loss of ridge contour as a result of physiologic

bone remodeling. Over the long term, prosthodontic complications, loss of

function, and inadequate bone for the placement of dental implants may result.

Guided bone regeneration techniques and the use of bone replacement materials

have both been shown to enhance socket healing and modify the resorption

process. This review describes the process of alveolar bone loss, materials for

extraction site grafting, and proposed mechanisms for ridge preservation.

INTRODUCTIONTHE PROBLEM OFEDENTULOUS BONE LOSS

Alveolar ridge resorptionis a phenomenon ob-served following the re-moval of teeth in an oth-erwise healthy individu-al. The condition appears

to be progressive and irreversible, re-sulting in a host of prosthodontic, es-thetic, and functional problems. Pos-textraction bone loss is accelerated inthe first 6 months, followed by a grad-ual modeling (change in size or shape)

and remodeling (turnover of existingbone) of the remaining bone, with asmuch as 40% of the alveolar height and60% of alveolar width lost in the first6 months.1 Loss of ridge height resultsin prosthetic instability as the crest ofthe ridge approaches muscle attach-ments and mobile mucosa. In extremecases, there may be involvement of the

maxillary sinus or nasal cavity, requir-ing extensive reconstructive surgeryfor traditional or implant-supportedprosthetics. Vital structures, such asthe mandibular neurovascular bundle,may become vulnerable due to expo-sure and impingement of the overlyingdenture.2 In the horizontal plane, boneloss occurs largely at the expense of the

buccal or facial bone.3 Ultimately, es-thetic tooth replacement with implantsis complicated by loss of tissue con-

tours.46

There was little concern aboutridge resorption until the latter part ofthe 20th century. Initial efforts to de-termine the etiology and prevent ridgeresorption focused on prosthetic tech-niques and patterns of denture wear.7,8

In the 1970s the development of knife-edge mandibular ridges was attributed


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ALVEOLAR RIDGE PRESERVATIONPART I

188 Vol. XXVII/No. Four/ 2001

to ill-fitting dentures and methods pro-posed for prevention of ridge resorp-tion included frequent modification ofthe prosthesis to compensate.9 Surgicaltreatment included sulcus extension,nerve repositioning, and skin grafting

of resorbed ridges. The concept of vitalroot retention was proposed based onthe observation that bone resorptiondid not occur around retained teeth,

but this was later abandoned due tosoft tissue complications.10,11 Using asimilar concept in the 1980s, ridgepreservation was done using hydroxyl-apatite (HA) in the form of root-shaped cones and particles placed intoextraction sites.12,13 Current methodsused to prevent ridge resorption in-clude placement of particulate auto-

grafts, allografts, alloplasts, and xeno-grafts.1420 These biomaterials presentadvantages and disadvantages and,depending on their structure and bio-chemical composition, may be resor-

bable or nonresorbable. With the ad-vent of endosseous implants, ridgepreservation techniques now appear tohave a dual focus, with implant sitedevelopment being the latest area of in-terest.

An estimated 20 million teeth areextracted in the United States each

year, with 40% of the population overage 60 having 1 or more edentuloussites.21 Many of these patients will suf-fer prosthetic complications or requireextensive reconstructive surgery due toedentulous bone loss. Unfortunately,ridge preservation has not advanced tothe standard of care, with most extrac-tions performed in the traditional fash-ion. In 1998, the US market for bonereplacement materials, including allo-plasts, xenografts, and human allo-grafts, was approximately $25 million(Source: US Markets for Dental Im-plants and Dental Bone Substitutes,Medical Data International, July 1999).Assuming 50% of these materials wereplaced into extraction sites at an aver-age cost of $100/cm3, and with a vol-ume of 0.25 cm3 per extraction site, itwould appear that only 500,000 sites,or 2.5% of extraction sites, were treated

with ridge preservation techniques.This is equivalent to the number ofroot form implants placed in 1998.

First attributed to disuse atrophy, itis now apparent that alveolar ridge re-sorption is a complex process involv-

ing structural, functional, and physio-logic components. Surgical traumafrom tooth extraction induces micro-trauma to surrounding bone, whichmay accelerate bone remodeling.22 An-atomic features, such as facial mor-phology, have been suggested to playa role. Age and sex are believed to havean effect on the extent and timing ofridge resorption, with females tendingto form knife-edge residual ridges.23,24

Systemic conditions such as osteopo-rosis, renal disease, and vascular andendocrine disorders may accelerate al-veolar bone loss by altering normal

bone physiology and metabolism.2527

Functional forces such as bruxism,complete denture wear, and heavy biteforces have been implicated as contrib-uting factors in accelerated boneloss.28,29 Presently, the molecular eventsin the bone remodeling process are be-ing studied in order to arrive at a morecomplete understanding of this disor-der.30

Observation of the dentoalveolarcomplex in a state of health reveals adynamic, interdependent system oftooth roots, periodontal attachment,and bone, vascular, and cellular ele-ments. It is well accepted that bone ismaintained in a state of health by theconstant compressive and tensile forc-es transmitted by the tooth roots.These forces, according to Wolffs law,cause a distinctive pattern of bone for-mation and maintenance along lines of

stress. Structural changes in the boneoccur through cellular processes of os-teoclastic resorption and osteoblasticdeposition of collagen and subsequentmineralization of the collagen matrix.Ultimately, it is by modification ofthese mechanical, cellular, and molec-ular events that ridge preservation may

be achieved following the loss of teeth.

DEVELOPMENT OF EXTRACTION-SITEGRAFTING PROCEDURES

Numerous animal and clinical studiesvalidate the concept of ridge preserva-tion by the placement of alloplasts intofresh extraction sites. Quinn and

Kent,12 in a study of hydroxylapatite(HA) implants placed in baboon jaws,concluded that maximum preservationof ridge form requires immediate graftplacement following tooth extraction.Bell31 reported in a clinical study ofHA cones and particles that the im-plantation of particles was associatedwith fewer intraoperative and postop-erative complications and was the pre-ferred method of ridge preservation.31

The routine use of HA cones for

ridge preservation has not seen wide-spread clinical acceptance, however.Human trials conducted at several cen-ters in the 1980s using HA cones dem-onstrated that the technique wasfraught with postoperative problems.Most of these problems relate to theproblem of maintaining adequate softtissue closure over the grafts.3235

SELECTION OF GRAFT MATERIALS

Generally, materials available for theplacement into extraction sites are con-

sidered either nonresorbable or resor-bable. Actually, even the nonresorbablematerials undergo some physiochemi-cal dissolution. However, for the pur-poses of this presentation, nonresorb-able materials will be discussed in thecontext of long-term ridge preserva-tion. The nonresorbable materials arenot suitable for placement into sitesthat may later receive dental implants.

There is a group of materials mar-keted as being resorbable but more ac-curately may be considered as transi-tional bone grafting materials. Forpractical purposes, these materialsmay be considered useful for increas-ing bone density and for medium-termridge preservation. They are especiallyuseful as adjuncts in guided tissue re-generation around teeth and implantsite development. The most importantfeature of these materials is the ability


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Barry K. Bartee


to place endosseous implants into thegrafted site, even in the presence ofsome unresorbed particles.

Finally, a third group of materialsmay be considered short-term resor-

bable materials because they are read-

ily resorbed and replaced by host tis-sue over the typical healing period.Similar in use to the transitional ma-terials, they may increase bone density,prevent early ridge resorption, and fa-cilitate the placement of dental im-plants. Due to the more rapid turnoverof these materials, they should be se-lected when implant placement will bedone within 3 to 6 months, before sig-nificant ridge resorption takes place.

MATERIALS FOR LONG-TERM RIDGE

PRESERVATION

Synthetic HA is a calcium phosphatematerial that varies in density, struc-ture, and surface chemistry. These var-iables, determined by the HA sourceand manufacturing process, affect the

bone bonding characteristics and lon-gevity of the material in situ.36 Partic-ulate, dense HA (Calcitite, Sulzer Cal-citek, Carlsbad, Calif; OsteoGraf/D,CeraMed Dental Products, LLC, Lake-wood, Colo.) is a proven material for

long-term ridge preservation.13,14,31,37

Upon implantation, the material bondsto adjacent bone via natural apatite de-position on its surface and interactionwith host cells. Particles placed in sitesremote from adjacent bone (more thana few millimeters) usually are sur-rounded by a dense fibrous tissue ma-trix. Due to their high modulus of elas-ticity and limited osteoconductive ac-tivity, these materials are not suitablefor placement into sites where im-plants are planned. However, these

same characteristics make them excel-lent for long-term ridge maintenance.

Porous corraline HA (Interpore/rm 200, Nobel Biocare, Yorba Linda,Calif), sourced from sea coral andtreated by a hydrothermal process, isuseful for long-term ridge preserva-tion. This material is essentially adense HA structure with interconnect-

ing pores that allow bone and soft tis-sue ingrowth within the particle.38,39

Bioactive glass (Bioglass, US Bio-materials Corporation, Baltimore, Md)materials are suitable for long-termridge preservation but may be more ex-

pensive than dense HA. Following im-plantation, a silica gel forms on theparticle surface, which is subsequentlymineralized with apatite crystals, pro-viding a bridge to host bone. Similar todense HA, these materials are osteo-conductive and are believed to be moreor less resorbable, depending on par-ticle size.15,40 Bioglass materials of smallparticle size distribution are claimed to

be osteoconductive and resorbable19

(Biogran, Implant Innovations Inc,Palm Beach Gardens, Fla; Perioglass,

Block Drug Inc, Jersey City, NJ).Porous polymethyl methacrylate

(PMMA) beads have also been used forridge preservation16 and treatment oflocal periodontal defects (BioplantHTR, Septodont, Inc, New Castle,Del). This material is reported to serveas a scaffold for new bone formationwhen in close contact with alveolar

bone but otherwise may be surround-ed by connective tissue. In one case re-port, unresorbed particles were ob-served 30 months following implanta-

tion, indicating potential as a long-term ridge preservation material.41

MATERIALS FOR TRANSITIONAL RIDGEPRESERVATION

Often, patients may decline implanttherapy at the time of tooth loss butexpress a desire to possibly have im-plants at a later date. Transitional ridgegrafting provides a means to preserve

bone mass, allowing the future place-ment of endosseous dental implants.Increased bone density may result aswell. It is well known that certain are-as, such as the posterior maxilla, healwith an increased pattern of trabecu-lation,5 and the placement of osteocon-ductive materials into these sites has

been shown to increase bone density.42

In addition, the placement of a transi-tional ridge preservation material im-proves the interim prosthetic result by

preserving ridge contour. There arethree primary goals of transitionalridge preservation: (1) modulation ofearly-stage ridge resorption, (2) in-creased bone density, and (3) facilita-tion of future dental implant surgery.

Transitional ridge preservation re-quires careful selection of grafting ma-terials and a complete understandingof their fate. If the wrong ridge pres-ervation material is placed (ie, denseHA), it may have to be removed in or-der to place implants or may preventimplant placement altogether.43 Mate-rial for transitional ridge preservationincludes anorganic bovine bone matrix(ABM), resorbable calcium phosphateceramics, and macroporous bioactiveglass.

Anorganic bovine bone is currentlyavailable in 2 forms: one is processed

by heat to remove organic components(OsteoGraf/N, CeraMed) of the boneand the other uses a chemical process(Bio-Oss, Osteohealth Co, Shirley, NY).Anorganic bovine bone matrix, as anaturally derived product, maintains asimilar crystalline structure, porosity,and carbonate content as human bonemineral and, due to the similarity tonative bone structure, is claimed toprovide a more physiologic osteocon-

ductive environment.44,45 Anorganicbovine bone matrix should be consid-ered to be a slowly resorbing material,however. Histological examination ofchemically deorganified ABM implantsreveals the presences of intact particlesfrom 44 to 60 months postimplanta-tion.42,46 Further, the efficacy of chemi-cal deorganification has recently beenquestioned. A report by Artzi andNemcovsky47 histologically revealedthe presence of amorphous proteinwithin the ABM particles, believed to

be of bovine origin. A comparativestudy of the methods for protein ex-traction in xenografts revealed elevatedresidual carbon (10 higher), elevatedresidual nitrogen (8 higher), and low-er bioactivity (10 lower) of chemicallyextracted ABM compared with heat-treated ABM (Tofe A, Sogal A, HanksT; unpublished data, June 1998).


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Synthetic resorbable materials areavailable in several forms. Amongthem are microporous resorbable HA(OsteoGraf/LD, CeraMed), micro-crystalline, nonceramic resorbable HA(OsteoGen, Impladent Ltd, Hollis-

wood, NY), and Beta-tricalcium phos-phate (B-TCP, Augmen, Miter Inc,Warsaw, Ind). While they are chemical-ly similar to bone, they differ fromABM in crystalline structure, carbonatecontent, and porosity and resorb pri-marily through physiochemical disso-lution and fragmentation.44 By provid-ing an osteoconductive lattice and amineral source, these material are be-lieved to increase bone density. Theuse of any of these materials alone willrequire from 4 to 12 months for signif-

icant graft turnover and bone forma-tion to occur. In large defects, even lon-ger periods may be required for ma-ture bone formation.

Due to the eventual resorption andreplacement of these materials by host

bone, the duration of ridge preserva-tion cannot be accurately predicted. Areasonable time frame for most sites, inthe authors experience, would be from3 to 5 years. After that time, physiolog-ic bone remodeling may ultimatelycause the grafted ridge to assume its

natural state, albeit at a slower pacethan if untreated. More studies are in-dicated in this area to determine thelong-term effects of the slowly resor-

bable bone replacement materials.

MATERIALS FOR SHORT-TERM RIDGEPRESERVATION

The objective of short-term ridge pres-ervation is to maintain bone mass dur-ing the initial healing stage in prepa-ration for dental implantsover a 3 to6 month period. Typically, deminer-alized freeze-dried bone allograft(DFDBA) or autogenous bone is com-

bined with a low-density HA, TCP, orABM product in a 50:50 or 75:25 ratio.The function of this composite graft isto provide a synergistic scaffolding fornew bone formation to take place. TheDFDBA or autogenous bone used alonehas not been shown to significantly in-

crease bone density in extractionsites,48,49 probably due to its rapid turn-over time. The addition of the calciumphosphate increases the turnover timeand provides a ready mineral source,enhancing the osteoinductive proper-

ties of DFDBA or osteogenic propertiesof autogenous bone.50 This techniqueresults in near total ridge preservation,providing a smooth, dense, and ana-tomically pleasing implant site. By con-trast, untreated extraction sites, on re-entry to place implants within 6months, often contain fibrous tissuethat must be removed and present anirregular surface for placing implants.

MECHANISM OF RIDGE PRESERVATION

While there is little doubt regarding

the benefits of alveolar ridge preser-vation, the exact mechanism has not

been fully explained in the literature.Alveolar bone resorption and socketrepair involve a complex cascade ofevents. Likewise, any successful ridgepreservation technique is likely to havemultiple mechanisms of action. Basedon the current understanding of bone-implant interactions, several key con-cepts emerge for consideration.

Biomechanical stimulation

Multiple authors have suggested thatthe grafting of extraction sites providesphysiologic and bioelectric stimulationof the adjacent bone via attachmentand load transmission during normal

jaw function.5153 Under a conventionalprosthesis, compressive, shear, andtensile forces are transmitted to thegrafted ridge by direct pressure fromthe prosthesis. Conceivably, the ran-dom orientation of a particulate graftcould transmit this load from particleto particle and from particle to bone ina manner similar to the periodontal ap-paratus of a natural tooth. Elevated re-modeling activity in adjacent bonemay result from mismatch in elasticmodulus between graft material and

bone,22 resulting in increased bonedensity. Finite element modeling of thehuman mandible indicates substantial

bending moments and tensile strains

in dynamic loading.54 Thus, indirectforces on the bone-graft interface maycontribute to bone preservation if theseforces are within the physiologic range.

Wound isolation and scaffolding effect

Bone formation in extraction sites pro-ceeds in an apical to coronal fashionalong a dense network of collagen fi-

bers. At 6 weeks, the socket is approx-imately two thirds filled with new

bone.55,56 Soft tissue proliferation andinvagination result in a convex bonedefect, with the bone fill somewhat be-low the level of the alveolar crest. Mod-eling of the alveolar crest follows, re-sulting in the high rate of bone lossseen in the first few months followingextraction.

The principles of guided tissue re-generation appear to be applicable tosocket healing. Wound isolation bymeans of an occlusive membrane has

been demonstrated to prevent invagi-nation of the aggressive oral epitheli-um into the healing socket, favoringthe repopulation of the socket withcells with bone regenerating potentialand leading to more complete bonefill.57,58 Isolation of the underlying tis-sue may also concentrate growth fac-tors and cellular elements necessary for

healing.Osteoconduction is the process

where the presence of a material pro-motes a bone healing responsethroughout a defined volume. Thepresence of a bioactive framework orscaffold allows bone formation to bedistributed more efficiently within agiven space,59 in this case, an extractionsite. In particular, anorganic bovine

bone has been shown to support oste-oblastic cell attachment and prolifera-tion.60 Thus, the combination of mem-

brane isolation and an osteoconductiveimplant material facilitates complete

bone fill in the socket.

Modification of cellular activity

The implantation of a bioactive sub-stance evokes a cellular response fromthe adjacent tissues. Whether this re-sponse is destructive or reparative in


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nature depends on the physiochemical,structural, and surface characteristicsof the implant. The host response ismediated by molecular cell signalingprocesses that modulate extracellularor intracellular events. The presence of

particulate graft materials may modifythe remodeling process by these mo-lecular mechanisms. For example, byeffecting a change in the closely cou-pled remodeling sequence, ie, decreas-ing the cellular resorptive phase by os-teoclast inhibition57 or increasing for-mation phase by osteoblastic stimula-tion, increased bone density couldresult. A current approach to modify-ing cellular behavior is to exploit thenormal physiologic mechanisms of cellproliferation and migration through

the use of biomimetic techniques. Forexample, the addition of a specific cell-

binding domain of type 1 collagen (P-15) to anorganic bovine bone increasescellular attachment and doubles theamount of DNA and protein synthesisof human fibroblasts in vitro.61,62 Asubsequent clinical study of ABM/P-15demonstrated superior results whencompared with DFDBA alone in hu-man osseous periodontal defects.63

These techniques not only offer insightinto the mechanism of action of current

materials but offer promise in devel-oping biomaterials with enhanced bio-activity.

A NEW STANDARD OF CARE?

Ridge resorption is a significant dis-order, and there are methods availablefor its prevention. What then preventsthis form of extraction therapy becom-ing the standard of care? Apparently,there are 3 major areas of concern: (1)issues of time, cost, and reimburse-ment, (2) uncertainty by dentists aboutwhich materials to use, and (3) lack ofa standardized and predictable tech-nique.

The cost/benefit issue needs to beexamined closely. The average extrac-tion site can be grafted with as little as$30 to $40 in materials and 1/3 hourof treatment time. When the benefits ofpreservation are explained and com-

pared with the devastating effects ofridge resorption, the majority of pa-tients, if they are able to afford evenroutine restorative care, will opt forridge preservation. Third-party reim-

bursement for bone regeneration is fre-

quently available and is included in thecurrent CDT-3/2000 insurance codes.Advances in the field of bone re-

placement materials have led to the de-velopment of a host of similar materi-als, all of which claim superiority overcompeting products. An increasingnumber of products inevitably leads toconfusion and uncertainty about ma-terial selection. For this reason, despitetheir interest, the majority of generaldentists choose to avoid bone replace-ment in their practices or referral for

the procedure due to fear of the un-known.

Similarly, the majority of surgicalspecialists do not routinely graft ex-traction sites. While reasons vary, pro-cedural difficulty and the additionaltime required for patient education andsurgery are common objections. Dentalspecialists are accustomed to havingthe need for their services explained, tosome degree, in advance by the refer-ring doctor. If ridge preservation is notincluded in the reason for the referral,

they may be reluctant to offer this ser-vice. In addition, the lack of standard-ized protocols and lack of long-termdata on ridge preservation materialsprevents some specialists from per-forming this procedure on a routine

basis.

CONCLUSION

The prevention of ridge resorption us-ing particulate grafting materials ispredictable, convenient, and availableat a reasonable cost. With the introduc-tion of membrane techniques, resultsare enhanced by providing contain-ment of the graft particles and preser-vation of soft tissue contours. Ridgepreservation may be long term or tran-sitional depending on the physico-chemical properties of the materialplaced into the sockets. Prosthodonticresults are substantially improved and

bone mass may be preserved for thesubsequent placement of dental im-plants. Further studies are needed toevaluate the long-term effects of ridgepreservation materials and to developstandardized protocols for their use.

Educational efforts should be devel-oped by implantologists, surgical spe-cialists, and academic training pro-grams to increase awareness, developreferral patterns, and encourage wide-spread use of this modality.

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bartee paper on ridge preservation

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